NEW PATIENT MEDICAL QUESTIONNAIRE
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- Suzanna Daniels
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1 NEW PATIENT MEDICAL QUESTIONNAIRE Ronald W. Lindsey, M.D. Professor and Chair The John Sealy Distinguished Centennial Chair in Rehabilitation Sciences Department of Orthopaedic Surgery and Rehabilitation The University of Texas Medical Branch Galveston, Texas (Tel) (Fax) UTMB Specialty Care Center at Victory Lakes 2240 Gulf Freeway South League City, TX (832) CLINIC LOCATIONS UTMB University Hospital Clinics (UHC) 1005 Harborside Dr. 5th floor Galveston, Texas (409) UTMB Orthopaedic Clinic at South Shore Harbour 3023 Marina Bay Drive Suite 101 League City, Texas (281) UTMB Clinic at the St. Luke's O'Quinn Medical Towers 6624 Fannin Suite 2600 Houston, Texas (409)
2 Today's Date: / / I. PERSONAL DATA NEW PATIENT MEDICAL QUESTIONNAIRE Name: DOB: Age: Sex: Race: Height: Weight: Cell # Home # Work # address(s): If we need to get in touch with you regarding and appointment change and/or in case of an emergency, who may we call? Please provide name and phone number(s). or II. SOCIAL DATA Marital Status: Number of Years: Children: Ages: Do you drink? How often? How much? Do you smoke? Packs/day? Do you now or have you ever used street drugs? What hobbies do you have? III. EMPLOYMENT DATA Job/Profession: Are you currently employed? Employer: How long have you worked at this particular job? Do you plan to return to work? If so, when would you like to return? Are you currently receiving compensation? If so, from what source? Is this injury job-related? Are you currently involved in a legal case for this injury? If so, who is your attorney? Are you currently disabled? (Yes or No) 2
3 If yes, are you seeking treatment in hopes of eliminating disability? IV. CURRENT MEDICAL HISTORY What, specifically, is your injury or complaint? When did this injury and/or symptoms first occur? Please describe the events leading to this injury or these symptoms: Please describe your symptoms, their location, and how often they occur: Has your condition prevented you from participating in any of your normal activities? If so, please list these: Have you had any of the following tests and when? MRI EMG/NCS Myelogram CAT Scan Discogram Bone Scan If surgery has been performed for your condition, what procedure and when? Was there ever a period following surgery when your symptoms were improved? If so, please describe: Were you advised to partake in physical therapy? What treatments did you receive and when? Have you had problems with any of the following? Urination Numbness Dizziness Mobility Bowel Movement Blurred Vision Others (explain) V. PAST MEDICAL HISTORY Have you or anyone in your family ever been diagnosed with any of the following? Myself Family Member Kidney Problems Ulcer Disease Cancer Heart Disease Diabetes High Blood Pressure Depression Schizophrenia Other 3
4 VI. WHAT OTHER DOCTOR(s) HAVE EVALUATED AND/OR TREATED YOUR CURRENT CONDITION? Name: Address: Telephone: VII. CURRENT PHYSICIANS PCP/ Internist (phone) Cardiologist (phone) Pain Management (phone) Neurologist (phone) Other (phone) VIII. MEDICATIONS ffff Please note, Dr Lindsey does not prescribe medication unless and/or until he orders a study and has received the results or unless he s performed surgery on you. ffff Please list all medications, which you are currently taking: (Please attached separate sheet if needed) Medicine Date Filled Last Taken List ALLERGIES to any medications and reaction: Are you taking any blood thinners or have you taken any recently? IX. SURGERY If surgery is an option and/or recommendation, would this be a consideration? (Yes or No) If no, why not? If yes, please circle a time-frame below: <1 month 2-6 months 6-12 month >1 year If surgery was recommended, do you have a preference in hospitals? (Yes or No) If YES, where would you prefer to have surgery? John Sealy/Rebecca Sealy Hospital Victory Lakes (outpatient) Christus St. John Hospital St Luke s Episcopal Hospital Memorial Hermann Southeast Hospital Methodist Hospital 4
5 PATIENT PAIN DRAWING Where is your pain now? Using the drawing below, mark the area(s) where you feel the following sensations: Aching + Numbness = Pins and Needles ^ Burning * Stabbing / Please include all affected areas. On a scale of 1-10 (1 being the worst and 10 being the best, how bad is your pain now? Please mark an X on the body above where the pain is the worst now on picture. Please mark on an X on the line below how bad your pain is now: No pain Worst possible pain If you are filling out this form electronically, you may describe your symptoms here: ffff Please forward all MRI and other imaging reports with this questionnaire. 5
6 Ronald W. Lindsey, M.D. Professor and Chair The John Sealy Distinguished Centennial Chair in Rehabilitation Sciences Department of Orthopaedic Surgery and Rehabilitation The University of Texas Medical Branch Galveston, Texas (Tel) (Fax) AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) BY UTMB I hereby give my permission to Dr. Ronald W. Lindsey and UTMB to release any and all information to those parties deemed appropriate by them which may be required in connection with my treatment. I also authorize and request any physician or other person or hospital/institution by whom or in which I have been treated for injury or illness to provide Dr. Ronald W. Lindsey full information relative to such treatment of me. Print Name: Date: Signature: Date: Parent Signature: Date: (For minor age patient s only) 5/26/10 6
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Patient Questionnaire for Men
Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.
TOTAL PAIN RELIEF Dear Pain Patient, We would like to welcome you to our office. We strive to offer the best pain care with a multi-disciplinary approach. The registration and medical history forms must
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
WELCOME to New Jersey Spine and Pain Institute
WELCOME to New Jersey Spine and Pain Institute Our Commitment to You We will provide you with the most appropriate care in the most time efficient fashion. We will treat you with respect and professionalism.
DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
New York Ophthalmology, P.C.
New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision
New Patient Registration Information
New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing